1. North Oaks Health System Health Transition Alliance Program Internship

2. Demographics  Age: 60 years old  Gender: Female  Race: White  Marital Status: Widowed with 3 adult children  Living Status: One room apartment  Employment Status: Disabled

3. Presenting Problem  Initial Problem  Pneumonia  Primary Problem  Reoccurring Pneumonia and Chronic Obstructive Pulmonary Disease (COPD)  Secondary Problem:  Pain management due to Rheumatoid arthritis, Osteoarthritis and Osteoporosis

4. Health Coaching Focus  Increase Health Literacy skills “Health literacy is the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.” -Healthy People 2010

5. Coaching Focus Continued  Encourage consistent use of COPD therapies  Oxygen use  Breathing treatments/inhalers  Evaluate medication regimen  COPD therapies  Anxiety/depression/pain medication  Develop financial plan/budget  Budget Binder

6. Coaching Progress  Coaching Sessions  Ten in home visits/15 phone calls  Week 1-2  ER Visit  COPD Exacerbation and Chronic Pain  Noncompliant with medication  Week 3-4  Completion of medication  Filled Spiriva

7. Coaching Progress Cont.  Week 5-6  Daily use of Spiriva  Oxygen use  Week 7-8  Cancelled appointment  Refused treatment  No oxygen use

8. Coaching Progress Cont.  Week 9-10  Understands and acknowledges COPD  Self Management  Short term and long term goals  Week 11  Taking consistent action

9. Behavior Change

10. Further Intervention  Facilitate healthy decision making  Health literacy  Continue emphasis on current goals  COPD therapies  Mobility  Continue financial plan  Budget binder

11. Challenges  Illness hindering progress of current goals  Ex) Ill patient unable to pursue current goal  Slow behavior change viewed as noncompliance  Basic Needs  Loss of a patient

12. Beneficial Experiences  Gratification of improving an individuals quality of life  Knowledge  Applied  Gained  Increased personal awareness of health and socioeconomic status

13. Future Health Coaches  Embrace every opportunity  Knowledge  Relationships  Advocate  You may be all they have  Organization  Record keeping/resource binder  Have FUN!  Make memories and form new bonds